Connecticut State University Student Health Services Form FOR OFFICE USE ONLY

 Complete  Missing: _______________________

Semester Beginning School Fall Spring of __________
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Last Name First Name MI

Date of Birth and Birthplace: Sex/Gender: Student ID #:

State of Connecticut and Connecticut State Universities REQUIRE:
Two doses for each Measles, Mumps, Rubella & Varicella One dose of Meningitis* Complete TB Risk and/or Test or Treatment
Vaccine & Date Given OR Incidence of OR Titer Test Results Requirements
Disease (attach lab report)
1 Measles #1 or MMR Date: Measles Titer Must be on or after 1st birthday.
Date Date :
Measles #2 or MMR Must be at least 28 days after 1st immunization.
Date: Result Pos Neg
2 Mumps #1 or MMR Date Mumps Titer Must be on or after 1st birthday.
Date: Date:
Mumps #2 or MMR Must be at least 28 days after 1st immunization.
Date: Result Pos Neg
3 Rubella #1 or MMR Date Rubella Titer Must be on or after 1st birthday.
Date: Date:
Rubella #2 or MMR Must be at least 28 days after 1st immunization.
Date: Result Pos Neg
4 Varicella #1 OR Incidence of OR Varicella Titer
Varicella is required only for students born on or after January 1, 1980
Date: Chicken Pox Disease Date: #1 Must be on or after 1st birthday;
Varicella #2 Date: #2 Must be at least 28 days after 1st immunization
Date: Provider Initials: Result Pos Neg
5 Meningococcal (must include groups A, C, Y&W-135) If living on-campus, your most recent vaccination must be within 5 years of your 1st day of classes at the
University. Please note: You will not be permitted to move in to campus housing without first providing the Student Health Service with this information.
Date(s):1._________2.__________ Brand of Vaccine: ______________________ I will not be living on-campus. I do not require this vaccine.
6 TUBERCULOSIS (TB) RISK QUESTIONNAIRE - A through D To be answered by the Student
A. Have you ever had a positive tuberculosis skin or blood test in the past? If you answer, “Yes,” Section 6b., “CHEST X-RAY”, must be completed Yes No
B. To the best of your knowledge have you ever had close contact with anyone who was sick with tuberculosis (TB)? Yes No
C. Were you born in one of the countries listed below? If yes circle country Yes No
D. Have you traveled or lived for more than one month in one or more of the countries listed below? If yes circle country. Yes No
Afghanistan,Algeria,Angola,Anguilla,Argentina,Armenia,Azerbaijan,Bahrain,Bangladesh,Belarus,Belize,Benin,Bhutan,Bolivia,Bosnia&Herzegovina,Botswana,Brazil,Brunei,Darussalam,Bulgaria,BurkinaFaso,Burundi,Cambodia,Camer
oon,CapeVerde,CentralAfricanRepublic,Chad,China,China:HongKongSpecialAdministrativeRegion,China:MacaoSpecialAdministrativeRegion,Colombia,Comoros,Congo,Côte d'Ivoire, Democratic People's Republic of Korea,
Democratic Republic of the Congo,Djibouti,DominicanRepublic,Ecuador,ElSalvador,EquatorialGuinea,Eritrea,Estonia,Ethiopia,Fiji,FrenchPolynesia,Gabon,Gambia,Georgia,Ghana,Guam,Guatemala,Guinea,Guinea-
Bissau,Guyana,Haiti,Honduras,India,Indonesia,Iraq,Iran,Japan,Kazakhstan,Kenya,Kiribati,Kuwait,Kyrgyzstan,LaoPeople'sDemocratic,Republic,Latvia,Lesotho,Liberia,Libyan,Arab,Jamahiriya,Lithuania,Madagascar,Malawi,
Malaysia, Maldives, Mali, Marshall Islands,Mauritania,Mauritius,Mexico,Micronesia(FederatedStates),Mongolia,Morocco,Mozambique,Myanmar(Burma),Namibia,Nauru,Niue,Nepal,Netherlands,Antilles,NewCaledonia,
Nicaragua,Niger,Nigeria,NorthernMarianaIslands,Pakistan,Palau,Panama,Papua,NewGuinea,Paraguay,Peru,Philippines,Poland,Portugal,Qatar,Republic of Korea, Republic of Moldova, Romania, Russian Federation, Rwanda, Saint
Vincent and the Grenadines, Sao Tome and Principe,Senegal,Serbia,Seychelles,SierraLeone,Singapore,SolomonIslands,Somalia,SouthAfrica,SouthSudan,SriLanka,Sudan,Suriname,Swaziland,Syrian,ArabRepublic,Tajikistan, Taiwan,
Thailand, The former Yugoslav Republic of Macedonia,TimorLeste,Togo,Trinidad&Tobago,Turks&Caicos,Tunisia,Turkey,Turkmenistan,Tuvalu,Uganda,Ukraine,United Republic of Tanzania, Uruguay, Uzbekistan, Vanuatu,
Venezuela(Bolivarian Republic),Viet Nam, Wallis and Futuna Islands, Yemen, Zambia ,Zimbabwe Based on WHO Global TB Report 2013
6. Prior BCG does not exempt patient from this requirement.
If you answer NO to all questions no further action is required.
If you answer YES to B-D of the above questions, Connecticut State University requires that a healthcare provider complete the following TB testing evaluation.

6a. TB BLOOD TEST OR 6a. TB SKIN TEST Use 5TU Mantoux test only. 6b. CHEST X-RAY Required within the past 6c. TB TREATMENT
Interferon-gamma 12 months for a previous or current positive MEDICATION (with dose):
release assay TB skin or blood test. Copy of X-ray report
Date: MUST be attached. X-ray is not needed if
asymptomatic AND completed full course of
Result: NEG POS treatment for the positive TB test (latent TB).
Date Interpretation (If no induration, mark 0) Chest X-ray Date: Frequency:
Planted: NEG POS
Date Result: Normal Abnormal Start & Completion Dates:
Read: _______mm of induration (Attach copy of report)

Other Vaccination History (Tetanus Booster within last 10 years and Hepatitis B series are recommended if not already completed)
Hepatitis B #1 Hepatitis B #2 Hepatitis B #3 Hepatitis Titer Result:
Date Date Date Date POS NEG
Last Tetanus Booster: Td or Tdap Other Vaccination: Other Vaccination: Other Vaccination:
Date:
Signatures
I confirm that the information above is accurate.

Clinician Signature: Date:

Student consent for treatment required to be signed (If you are less than 18 years of age signatures of both the student and one parent/guardian are required)
I hereby grant permission for the Connecticut State University Health Services staff to provide me with appropriate medical and mental health treatment including medications for treatment of
illnesses/injuries and to arrange for any emergency medical care if circumstances at that time make it impossible for me to make such decisions. Furthermore, I understand that University Health
Services staff may disclose my student medical records and/or information from such records to appropriate University personnel and/or Emergency Contacts identified within my records in the event
of a health or safety situation as determined by the Student Health Services staff.
Signature of Student Signature of Parent/Guardian Date:
 Connecticut State University Student Health Services Form
Page 2
PLEASE RETAIN A COPY OF THIS HEALTH FORM FOR YOUR RECORDS BOTH SIDES/PAGES OF THIS FORM MUST BE SUBMITTED
Student Name Home/Personal Email Address Student Cell Phone

Permanent Home Information Notify in Case of Emergency

Home Phone Cell/Work Phone Name Relationship

Street Address Home Phone Cell/Work Phone

City State Zip Street Address

City State Zip

Personal Physician/Healthcare Provider Address:

Name:
Telephone #: FAX #
Personal Medical History- Please circle all below that apply to you.
Check here if none apply
Alcohol/Substance Abuse Dental Problems Mononucleosis
Anemia Diabetes Mumps
Anxiety/Depression/Mental illness Gastrointestinal Conditions/IBS Rheumatic Fever
Asthma Gynecological Conditions Seizures
Cancer Hepatitis B or C Disease Sickle Cell Disease
Cardiac Condition/Heart Murmur High Blood Pressure Thyroid Disorder
Coagulation/Bleeding Disorder HIV/AIDS Tuberculosis
Concussion Measles Other – please explain
Allergies: Drugs & Other Severe Adverse Reactions - Please complete all that apply and explain reaction.
Check here if you have no allergies
Medication Food

Insect Environmental

Seasonal X-ray Contrast

Are any life threatening? Yes No Do you carry an Epi Pen? Yes No

Prior Hospitalizations or Surgeries - Please list dates and reasons.

Medications – Frequent or regular- Please list all prescriptions, natural and over the counter medications.

Is there any other medical information or health concern that we should know about? Please attach any additional information to
further explain your condition(s) or concern(s).

Current Height**: Current Weight**: Last Blood Pressure (if known)**:

**not required
Student - Did you sign the Consent for Treatment on Page 1?
Please return by mail or fax to the appropriate Health Service listed below.

Central Connecticut State University
University Health Service
1615 Stanley Street
New Britain, CT 06050
860/832-1925 Fax 860/832-2579
Eastern Connecticut State University
University Health Service
185 Birch Street
Willimantic, CT 06226
860/465-5263 Fax 860/465-4560
Southern Connecticut State University
University Health Service
501 Crescent Street
New Haven, CT 06515
203/392-6300 Fax 203/392-6301
Western Connecticut State University
University Health Service
181White Street
Danbury, CT 06810
203/837-8594 Fax 203/837-8583